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Ethical cost of dispensing doctors

June 13, 2018

BY DR CHRIS MOY, CHAIR, AMA ETHICS COMMITTEE

Amid the review of the AMA Position Statement on Doctor’s Relationships with Industry 2012, delegates at the recent AMA National Conference debated the ethics of doctors dispensing pharmaceuticals. They supported a motion that doctors should not dispense pharmaceutical or other therapeutic products unless there is no reasonable alternative and, where dispensing does occur, it should not be undertaken for material gain.

Current AMA policy advises that doctors should not dispense pharmaceuticals or other therapeutic products unless there is no reasonable alternative. Prior to 2010, the AMA position included an additional qualification that doctors should not dispense for material gain, should it be required (material gain refers to making a profit over and above recovery costs, such as the cost of purchasing, storing and disposing of the products).

In 2010, the words “for material gain” were removed from the policy, opening the way for doctors to make a profit from dispensing. The Ethics and Medico-Legal Committee (EMLC), responsible for coordinating the policy review, believes this particular position places doctors in an, actual or perceived, conflict of interest and that the AMA should return to its former position not to dispense for material gain. Reinstating the qualifier of ‘material gain’ removes the perception (and any incentive) that doctors profit from prescribing or recommending therapeutic products to patients (a clear conflict of interest).

As Chair of the EMLC, I introduced the National Conference session on dispensing, outlining a range of issues for delegates to consider. First and foremost, it was important to acknowledge that general practitioners feel under assault by pharmacists encroaching into their space, for example by providing vaccinations and sickness certificates, and some GPs may feel returning to a position that opposes doctors making a material gain from dispensing is a surrender to the pharmacists.

But there is clear potential for doctors who make a profit from dispensing to (inadvertently or otherwise) overprescribe certain treatments, potentially causing harm to patients, undermining the quality use of medicines and contributing to the inappropriate use of healthcare resources.

Further, any model for prescribing where the assessment and sale of a product is inextricably linked (for example, as used by hearing centres) introduces a conflict of interest and undermines the advice provided to patients and their trust.

While some doctors will argue they can manage their own conflicts of interest, the AMA’s Guidelines for Doctors on Managing Conflicts of Interest in Medicine 2018 states:

Doctors will often face uncertainty as to whether they have an actual or perceived conflict of interest and, if so, what actions, if any, need to be taken in response. A doctor should recognise that they are ultimately not in a position to make this determination and should either seek the advice of, or delegate the decision to, an independent party.

Because of the massive power differential in the doctor-patient relationship, the patient is not in a position to decide for themselves whether or not the doctor has a conflict of interest when prescribing a treatment.

While an individual doctor might feel indignant that anyone would doubt their ability to properly assess and manage their own conflicts of interest, a doctor’s financial interest in dispensing clearly has the potential to impair objectivity and professional judgement. It would only require a few proven instances of material gain leading to inappropriate prescribing and dispensing to seriously damage the trust in all doctors.

As the AMA, we consistently highlight the conflicts of interest of pharmacists who sell a wide range of therapeutic (and other) products to consumers – Should we be in a race to the bottom to do the same? And would any financial gain be worth the cost – in loss of trust by the community? Thankfully, our National Conference delegates said “no”.